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Prior authorization for medical necessity is required. The limits are 4 tablets per day.

ACCOLATE®

02/01/05

The limits are 2 tablets per day.

ACETAMINOPHEN WITH CODEINE

03/23/04

The limits are 13 tablets per day for acetaminophen with codeine 300mg/15mg, 12 tablets per day for acetaminophen with codeine 300mg/30mg, and 6 tablets per day for acetaminophen with codeine 300mg/60mg.

ACIPHEX®

02/18/02

Aciphex may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day for the 20mg tablets and 1 capsule per day for the 5mg and 10mg sprinkle.

ACTEMRA®

01/01/14

Actemra subcutaneous injection may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 4 syringes per 28 days.